Palpitations
Palpitations: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
Defined as a conscious awareness of one’s heartbeat, palpitations are usually felt over the precordium or in the throat or neck. The patient may describe them as pounding, jumping, turning, fluttering, or flopping or as missing or skipping beats. Palpitations may be regular or irregular, fast or slow, and paroxysmal or sustained.
Although usually insignificant, palpitations may result from a cardiac or metabolic disorder and from the effects of certain drugs. Nonpathologic palpitations may occur with a newly implanted prosthetic valve because the valve’s clicking sound heightens the patient’s awareness of his heartbeat. Transient palpitations may accompany emotional stress, such as fright, anger, or anxiety, or physical stress, such as exercise and fever. They can also accompany the use of stimulants, such as tobacco and caffeine.
To help characterize palpitations, ask the patient to simulate their rhythm by tapping his finger on a hard surface. An irregular “skipped beat” rhythm points to premature ventricular contractions, whereas an episodic racing rhythm that ends abruptly suggests paroxysmal atrial tachycardia.
Act Now: If the patient complains of palpitations, ask him about dizziness and shortness of breath. Then inspect for pale, cool, clammy skin. Take the patient’s vital signs, noting hypotension and an irregular or abnormal pulse. If these signs are present, suspect cardiac arrhythmia. Prepare to begin cardiac monitoring and, if necessary, to assist with synchronized cardioversion or defibrillation. Start an I.V. line to administer an antiarrhythmic, if needed.
Assessment
History
If the patient isn’t in distress, perform a complete cardiac history and physical examination. Ask if he has a cardiovascular or pulmonary disorder, which may produce arrhythmias. Does he have a history of hypertension or hypoglycemia? Be sure to obtain a drug history. Has he recently started cardiac glycoside therapy? Also, ask about caffeine, tobacco, amphetamine, and alcohol consumption.
Physical examination
Perform a complete cardiac and pulmonary assessment. Then explore associated symptoms, such as weakness, fatigue, and angina. Finally, auscultate for gallops, murmurs, and abnormal breath sounds. Cardiac monitoring may be indicated when a cardiac arrhythmia is suspected. (See Palpitations: Causes and associated findings, pages 226 and 227.)
Pediatric pointers
Palpitations in children commonly result from fever and congenital heart defects, such as patent ductus arteriosus and septal defects. Because many children can’t describe this complaint, focus your attention on objective measurements, such as cardiac monitoring, physical examination, and laboratory tests.
Medical causes
Anemia
Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.
Anxiety attack (acute)
Anxiety is the most common cause of palpitations. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.
Cardiac arrhythmias
Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate as well as decreased blood pressure, confusion, pallor, oliguria, and diaphoresis.
Hypertension
With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg.
Hypocalcemia
Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.
Hypoglycemia
When the blood glucose level drops significantly, the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually, the patient may develop central nervous system reactions. These include blurred or double vision, muscle weakness, hemiplegia, and an altered LOC.
Mitral prolapse
A valvular disorder, mitral prolapse may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.
Mitral stenosis
Early features of mitral stenosis — a valvular disorder — typically include sustained palpitations accompanied by exertional dyspnea, fatigue, paroxysmal nocturnal dyspnea, and atrial fibrillations. Auscultation also reveals a loud S
1 or opening snap and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, peripheral edema, jugular vein distention, ascites, and hepatomegaly.
Pheochromocytoma
Pheochromocytoma, a rare adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.
Sick sinus syndrome
A patient with sick sinus syndrome may experience palpitations as well as bradycardia, tachycardia, chest pain, syncope, and heart failure.
Thyrotoxicosis
A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.
Wolff-Parkinson-White (WPW) syndrome
Seen in children and adolescents, WPW syndrome results in recurrent palpitations and frequent episodes of paroxysmal tachycardia.
Other causes
Drugs
Cardiac glycosides and other drugs that precipitate cardiac arrhythmias or increase cardiac output can cause palpitations. Ganglionic blockers, beta-adrenergic blockers, calcium channel blockers, atropine, minoxidil, and sympathomimetics, such as cocaine, can also cause palpitations.
Exercise
Palpitations can occur normally with exercise. Patients with coronary heart disease, hypertension, mitral valve prolapse, and cardiomegaly may experience palpitations with exercise.
Herbal remedies
Ginseng and other herbal remedies may cause adverse reactions that include palpitations and an irregular heartbeat.
Nursing considerations
Prepare the patient for diagnostic tests, such as an electrocardiogram and Holter monitoring. Provide supplemental oxygen, as indicated. Assess the patient for electrolyte imbalances as a potential cause for the condition. To alleviate the anxiety that may arise with palpitations, provide a quiet, comfortable environment.
Patient teaching
If the patient’s palpitations are related to anxiety, provide information about anxiety and stress management. Refer him to community support services for stress management and therapy. Reinforce the need to avoid caffeine and provide information on alcohol and smoking cessation programs, as appropriate.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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